Cataract surgeons discuss use of capsular tension rings in eyes with pseudoexfoliation
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Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.
Pseudoexfoliation syndrome often coexists with cataract in older age and poses significant challenges for the cataract surgeon. The capsule is more fragile, the zonules are weaker, and pupil dilation is poor, leading to a higher risk of intraoperative and postoperative complications. The use of capsular tension rings may help, but not all surgeons agree that their routine use is worthwhile. Our monthly discussion focuses on this topic, with Timothy Page, MD, and Audrey R. Talley Rostov, MD, expressing their points of view. We hope you enjoy it.
Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor
A game changer in maintaining stability
Pseudoexfoliation (PEX) syndrome is a challenging ocular condition that ophthalmologists frequently encounter.
It is characterized by the deposition of abnormal fibrinogranular material in the eye and presents several complications, one of which is IOL subluxation. In such cases, the use of a capsular tension ring (CTR) can be a game changer in maintaining long-term ocular stability. With the right training and expertise, the risk of using a CTR is low, making it an indispensable tool in the management of PEX.
Drawing from my experience in repairing many subluxed IOLs in eyes with PEX, and because a CTR is proven to provide stability in zonular disorders, I am an advocate for placing a CTR at the time of cataract surgery. A CTR distributes the collective strength of the zonules across areas of weakness and provides an anchoring point for a belt loop or suture in the event of subluxation in the future. When I manage PEX patients with subluxed IOLs, I often regret that the primary surgeon did not place a CTR at the time of cataract surgery. If they had, the patient may have been able to avoid scleral fixation surgery, or at least a CTR would be in the capsular bag equator to fixate the IOL with a belt loop or suture.
Surgeons may be reluctant to implant a CTR for fear of causing a dialysis due to the blind nature of CTR insertion under the iris. However, with today’s CTR injectors and proper training, the risk of inserting a CTR is minimal. I have outlined the steps for CTR insertion in the article “S means stop,” offering a step-by-step guide on how to safely insert CTRs.
Given the low risk of insertion and the substantial risks and costs of additional surgery to correct subluxation, the placement of a CTR can mitigate future complications and reduce the need for unnecessary surgical interventions. I strongly advocate for their inclusion during PEX cataract surgery; however, long-term randomized prospective studies would be helpful on this topic.
- References:
- Lee DH, et al. J Cataract Refract Surg. 2002;doi:10.1016/s0886-3350(01)01174-9.
- Menapace R, et al. J Cataract Refract Surg. 2000;doi:10.1016/s0886-3350(00)00446-6.
- Page TP Sr, et al. J Cataract Refract Surg. 2021; doi:10.1097/j.jcrs.0000000000000467.
- For more information:
- Timothy Page, MD, co-chief of anterior segment surgery and professor of ophthalmology at Oakland University William Beaumont School of Medicine, can be reached at tpagemd@yahoo.com.
Only in specific cases
I do not routinely use capsular tension rings (CTRs) in cases of pseudoexfoliation (PEX) syndrome because I believe it is rather unnecessary and not worth the extra time and cost involved.
Unless there is significant zonular weakness, CTRs are not going to help my surgery or the outcomes of my surgery, and postoperatively, I have not seen in my patients any significant IOL rotation or dislocation. On the other hand, late dislocation of the IOL-capsular bag complex may occur despite the use of CTRs, and some of these cases have been previously described.
Specific patients, of course, can benefit from the use of CTRs. Connective tissue disorders that may coexist with PEX, such as Marfan syndrome, are definitely an indication, and so are trauma cases in which zonule dialysis is present and cases of congenital lens coloboma. In these patients, the decision to use a CTR is taken upfront. Intraoperatively, if I see that the zonules are weak and the bag is floppy and not acting properly during phacoemulsification or IOL implantation, I do not hesitate to place a ring to strengthen that area and maintain the proper orientation of the IOL-capsular bag complex. But I do not make it standard in cases of either PEX or high myopia, as some of my colleagues do. Unless there is a distinct indication, I do not use them routinely to prevent an issue that I believe is not likely to happen.
- References:
- Gimbel HV, et al. J Cataract Refract Surg. 2005;doi:10.1016/j.jcrs.2005.06.053.
- Kocabora MS, et al. Ann Ophthalmol (Skokie). 2007;doi:10.1007/BF02697324.
- Oner FH, et al. J Cataract Refract Surg. 2006;doi:10.1016/j.jcrs.2006.05.016.
- Scherer M, et al. J Cataract Refract Surg. 2006;doi:10.1016/j.jcrs.2006.01.041.
- For more information:
- Audrey R. Talley Rostov, MD, director of cornea, cataract and refractive surgery at Northwest Eye Surgeons in Seattle, can be reached at atalleyrostov@nweyes.com.
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